Prevalence of chronic kidney disease and its associated factors among diabetes mellitus patients in Dessie Referral Hospital, South Wollo, Ethiopia

Diabetes mellitus shares a large proportion of kidney failure. Despite many patients suffering from diabetes mellitus and its complications in Dessie City, no study was conducted in the study area that shows the prevalence and associated factors of chronic kidney disease among diabetes mellitus patients. Therefore, this study aims to assess the prevalence of chronic kidney disease and its associated factors among adult diabetes mellitus patients attending Dessie Referral Hospital, South Wollo, Northeast Ethiopia. An institutional-based cross-sectional study was conducted at Dessie Referral Hospital among 267 randomly selected adult diabetic patients. Data were collected using questionnaires administered by interviewers. The glomerular filtration rate was estimated from serum creatinine levels. Data were entered into Epi-data version 4.6 and analyzed using SPSS version 26 software. Multi-variable logistic regression was used to determine the strength of association for the associated factors of chronic kidney disease. Variables with a p value < 0.05 were used to ascertain statistically significant associations. A total of 267 diabetic patients participated in this study. About 104 (39%) of the respondents were female and from the total, 133 (48.1%) were hypertensive. The overall prevalence of chronic kidney disease in this study was 31.5% (95% CI 25.3–37.1%). Being older (p-value = 0.003) and having hypertension (p-value = 0.043) were significant factors for chronic kidney disease among diabetes mellitus patients. This study found a high prevalence (31.5%) of chronic kidney disease among diabetic patients. Older age, having hypertension, and elevated serum creatinine were statistically significant associated factors of chronic kidney disease among patients with diabetes mellitus. Thus, clinicians should be aware of the high prevalence of chronic kidney disease in Dessie City. Moreover, emphasis should be given for old age and hypertension as contributing factors to the high prevalence in diabetic patients.


Study population
All adult DM patients attending at Dessie Referral Hospital were the source population and all adult DM patients (age ≥ 18 years) who were attending at the Hospital during the data collection period and who were willing to participate in the study were included as a study population.

Exclusion criteria
Patients who were pregnant, known to have liver disease (cirrhosis), hospitalized, febrile, and had marked muscle wasting were excluded from the study.

Sample size determination and sampling procedure
The sample size was calculated using the single population proportion formula with the following assumptions; 95% confidence level, 5% margin of error and the prevalence of CKD among patients with DM at Gondar Tertiary Hospital, Northwest, Ethiopia 19 , which was 21.8% and the final sample size became 267.Study subjects were selected using a systematic random sampling technique.

Study variables
The outcome variable for this study was the prevalence of CKD (Yes or No) among patients with DM and the independent variables were sociodemographic factors (age, sex, marital status, educational level of respondents, income per month) and clinical and behavioral factors (hypertension, alcohol consumption, smoking, types of diabetes, duration of diabetes, systolic blood pressure, diastolic blood pressure, body mass index (BMI), fasting blood glucose, and blood urea level).

Anthropometric measurement
Physical measurements such as weight, height, BMI, and blood pressure were taken using standardized methods and adjusted equipment.The weight was measured in kg with light clothing and no wearing of shoes.The height was measured in centimeter using a vertical scale without shoes and in an upright position then, BMI was calculated as weight divided by height squared (kg/m 2 ) and values of BMI was classified as follows: BMI ≤ 18.5 kg/m 2 underweight, BMI = 18.5-24.9kg/m 2 normal weight, BMI = 25-29.9kg/m 2 overweight and BMI ≥ 30 kg/m 2 obese.
Blood pressure was measured according to WHO guidelines using an automated sphygmomanometer after participants rested for at least five minutes or 30 min for those taking hot drinks like coffee.The sphygmomanometer cuff was normally placed smoothly and snugly on the upper arm.The arm is flexed at the heart level, while the subject is seated with the arm supported.The cuff is inflated until the radial pulse disappears.As the valve is gradually opened, the pressure of the cuff (slowly) decreases.When the cuff pressure is equal to the arterial systolic pressure, blood begins to flow through the cuff; audible sounds are heard using a stethoscope.Thus, the first knocking sound (Korot koff) was the subject's systolic pressure, and when the knocking sound disappeared, that was the diastolic pressure (such as 120/80).Hypertension was defined as mean blood pressure ≥ 140/90 mmHg or medical history of hypertension.

Biochemical/laboratory tests
After collecting about 5 ml of blood sample (at least after eight hours of fasting) by the laboratory technologist with the standard venipuncture technique; serum glucose, serum creatinine and blood urea levels were quantified from it.Serum creatinine (Scr) was estimated using the alkaline picrate ("Jaffe") method using a commercially available kit.
Freshly voided urine was also collected with clean and dry containers and the dry-reagent test strip technique (dipstick) was used for qualitative and semi quantitative estimation of proteinuria.The presence of albuminuria (+ 1 or more) in urine was defined as proteinuria.eGFR was calculated from serum creatinine (Scr) using the formula (CKD-EPI 2009) and CKD was defined as eGFR < 60 ml/min/1.73m 2 and/or albuminuria.

Data quality control
To ensure the quality of the data, prior to data collection, the principal investigator conducted data collection training.The data collection tool was prepared in English and then translated into Amharic.The questionnaire was pretested in 15 patients at Tikur Anbessa Specialized Hospital (TASH) before proceeding with the research participants to check the validity and appropriateness of the questions included there.To ensure the quality of laboratory analysis, the standard operating procedures (SOPs) of the DRH clinical chemistry laboratory were strictly followed.Laboratory test data collectors were professional laboratory technologists and nurses under the close supervision of the investigator.Thus, all tests were standardized and automated, and all variables were filled in the data extraction format daily.

Data processing and analysis
After the data was collected, it was properly coded and entered in the Epi-data version 4.6 (EpiData Softwarehttp:// www.epida ta.dk) and then exported to a statistical package for the social science (SPSS) version 26 software (Downloading IBM SPSS Statistics 26) for analysis.Bi-variate and multi-variable logistic regression analysis was used to determine the potential determinants of risk factors for CKD among DM patients and a p-value of < 0.05 with a 95% confidence level was used to declare a significant statistical association.

Ethical considerations and consent for participants
Ethical approval for the research was obtained from Addis Ababa University, College of Health Sciences, and School of Graduate Studies, Department of Medical Physiology Research Ethics Review Committee.A written permission letter was obtained from hospital managers.Written informed consent was obtained from the participants and from their guardians for those who are illiterate.Confidentiality was maintained by omitting direct personal identifiers on the questionnaire, using code numbers, storing data locked with a password, and not misusing or wrongfully disclosing their information.Participants were also informed that participation was voluntary and that they could withdraw from participation in the study at any stage if they were not comfortable with the investigation.Written informed consent was obtained from the study participants prior to starting the study.

Sociodemographic characteristics
A total of 267 DM patients (163 males and 104 females) participated in this study.Concerning age, 204 (76.4%) of the sample were found in the age group of less than 60 years.Regarding marriage, 233 (87.3%) of the samples were married and 71 (26.6%) did not attend formal education (Table 1 www.nature.com/scientificreports/

Behavioral and clinical characteristics of the participants
The study shows that 92.1% and 94.4% of the study participants never smoked cigarettes and never drank alcohol, respectively (Table 2).
Regarding nutritional status, 71 (26.6%) of the study participants had a normal BMI.High SBP and normal DBP were reported among 177 (66.3%) and 186 (69.7%) of the participants, respectively.About 133(49.8%) of the study participants were hypertensive.Regarding the type of DM, the majority of study participants (92.5%) were type-2 DM patients (Table 2).

Risk factors for CKD
In the bivariate analysis, older age, obesity, elevated systolic blood pressure (SBP), elevated diastolic blood pressure (DBP), hypertension, longer duration of diabetes, elevated SCr, elevated BUN, and smoking habit were significantly associated with CKD (Table 6).
After incorporating all the variables of significance (p-value < 0.25) variables in the bivariate logistic regression analysis, multivariable logistic regression analysis was performed to identify the risk factors independently associated with CKD.The multivariable logistic regression analysis showed that only older age, HTN, and elevated SCr were independently associated with CKD (Table 7).

Discussion
This study has assessed the prevalence and risk factors of CKD among diabetic adults at Dessie Referral Hospital using an estimated glomerular filtration rate (eGFR) and proteinuria (dipstick).The estimated total prevalence of CKD was 31.5% (95% CI 25.3-37.1%).
A similar study from the UK presented a similar CKD prevalence (31.5%) 21.The finding of our study is also relatively similar to those observed in China (29.6%) 22 and Spain 27.9%) 23 .
Our prevalence estimate of CKD was much lower than the study done in Asella that showed the overall prevalence of CKD was 86.3% by C-G equation 14 .Possible reasons for this difference might be the variation in the sensitivity of the estimators used and the difference in the study design.The study 14 used the C-G equation for the estimation of GFR, which underestimates the GFR, thereby increasing the prevalence of CKD.Different results showed that the prevalence of CKD and its staging can vary even within analogous populations depending on the estimators used 24 .The CKD-EPI equation has been advised to obtain a more accurate GFR in numerous African people 25 .
On the contrary, the estimated prevalence of CKD in our study was higher than that of studies conducted in Gondar (25.3%) 19 and Butajira (23.8%) 26 .The possible reasons for this variation are differences in the mix of cases (in terms of age), sample size, and creatinine assays.In our sample, there are more aged participants compared to the previous two studies.Furthermore, the latter study (Butajira) used only eGFR to estimate the prevalence of CKD, which possibly reduced the prevalence of CKD.
However, the estimated prevalence of CKD in this study appeared low compared to most other studies conducted outside the country, which revealed a prevalence of CKD based on eGFR < 60 and ACR in the range of 34-86 [27][28][29][30][31][32] .A cross-sectional study conducted in the USA also showed that the prevalence of CKD in patients with diabetes was found to be 39.7% 33 .
The lower prevalence in this study may be attributed in part to the fact that we did not use the ACR or microalbuminuria test.Furthermore, ethnic differences, sample size variation, and differences in sensitivity of the estimators used and lifestyle can contribute to the observed difference.
The prevalence of CKD in this study was approximately 3 times higher than that reported from Botswana (8.4%) 34 .This might be because they used only eGFR to estimate the prevalence of CKD, but in this study, we used both eGFR and proteinuria.
A similar institutional-based study conducted in 2016 at Dessie Referral Hospital (the same sitting as this one) showed the overall prevalence of CKD as 26.3% 17 .In this previous study, only 13% of the participants had CKD defined by eGFR < 60 ml/min/1.73m 2 using the MDRD equation, and the remaining (13.3%) had CKD defined by albuminuria using the urine dipstick test.The prevalence of CKD in this report using the MDRD equation is lower than the finding in our study, which is done by the CKD-EPI equation (26.3% vs. 31.5%).This could be due to differences in the case mix (in terms of age and being hypertensive) and the difference in the equation (formula) that we used to determine the eGFR.There are more hypertensive participants in our study than in the previous study, which is 133(49.8%).vs 99 (30.7%).In the same way, the numbers of aged participants in this study are more than in the previous study (23% vs. 14.9%).
Regarding risk factors, this study found a significant association between older age and CKD defined by CKD-EPI (p = 0.003) equation.This result is consistent with the findings from other studies 19,26,35,36 .In elderly patients, glomerular filtration may decrease as part of the body's aging process 37 .This is because as age increases, there is a progressive loss of nephrons and decreased renal blood flow 38 .It means that as age increases, the GFR will decrease, causing a higher number of people with CKD in the older age groups.Thus, CKD screening in the elderly age group is an important strategy to improve outcomes.
This study also reveals that hypertension was independently associated with CKD (p = 0.043) defined by the CKD-EPI equation.This is consistent with other related studies 14,39,40 .Systemic hypertension is transmitted by intra glomerular capillary pressure leading to glomerulusclerosis and loss of kidney function 41 .Therefore, blood pressure control is a key component in preventing and slowing the progression of CKD.
Our study indicates that several participants, 14 (8.23%) of participants whose scr were in the normal range had mild to moderate RI (stage 3 CKD) indicating that the lower prevalence of impaired renal function observed through serum creatinine.This supports the literature findings that state serum creatinine alone is not a sensitive method to assess renal function in asymptomatic CKD patients.Thus, as stressed by current guidelines, it is recommended not to use (SCr) alone to assess kidney function, because it fails to identify many patients whose kidney function is reduced while they remain within the normal range 18,42 .

Limitations of the study
The results of this study need to be interpreted with some limitations to put the findings into perspective.Albumin creatinine ratio is a better indicator in the detection of CKD, but, for feasibility reasons, we used semi quantitative methods (dipstick) to assess proteinuria.Only single serum creatinine and urine protein measurements were performed (instead of at least two serum levels performed three months apart), and therefore we Vol:.(1234567890

Conclusion
The study revealed that the prevalence of CKD is high in the study area.Older age, the presence of HTN, and elevated serum creatinine were associated factors of the development of CKD in patients with DM.Therefore, clinicians in outpatient diabetes clinics should be aware of the high prevalence of CKD, and elderly people and patients with HTN should receive special attention, as they are more at risk of CKD.The renal insufficiency corresponding to participants in stage 3 CKD was also higher despite having normal scr levels, indicating that current screening methods (assessment of scr alone or urine dipstick for albuminuria) are decreasing the prevalence of CKD in DRH.Therefore, regular evaluation of renal function by eGFR and albuminuria (instead of scr alone) will help to recognize CKD at an early stage and to take an appropriate intervention.

Table 2 .
Behavioral and clinical characteristics of the study participants (n = 267) in DRH, South Wollo, Northeast Ethiopia, 2020.HTN Hypertension, FBG Fasting blood glucose, BMI Body mass index, SBP Systolic blood pressure, DBP Diastolic blood pressure, BUN Blood urea nitrogen, SCr Serum creatinine, N Number.

Table 4 .
Prevalence and stage of CKD.eGFR Estimated glomerular filtration rate, N Number, % Percent.

Table 5 .
Kidney function in DM patients with normal Scr assessed using CKD-EPI equations at DRH, South Wollo, Northeast Ethiopia, GFR Glomerular filtration rate, CKD-EPI Chronic Kidney Disease-Epidemiological Collaboration, N Number.GFR category (ml/min/1.